Provider Demographics
NPI:1245774819
Name:PENGELLY, DEMELZA MARY (MSW, LCSW, LCAS-A)
Entity Type:Individual
Prefix:
First Name:DEMELZA
Middle Name:MARY
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 GRIST MILL LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-9513
Mailing Address - Country:US
Mailing Address - Phone:617-800-3701
Mailing Address - Fax:
Practice Address - Street 1:300 VEAZEY RD
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509
Practice Address - Country:US
Practice Address - Phone:199-764-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221410104100000X
NCP011117104100000X
NCC0121211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker